Vocal Function Exercises Laryngeal Adduction Exercises Angie Predmore Robyn Renwick Purpose • To improve vocal quality • Increase muscle activity Laryngeal Adduction Exercises Pushing/pulling Holding breath Glottal attack Pseudo supraglottic swallow Who? • used with patients with poor vocal fold adduction (hypo- adduction) • laryngeal trauma (may result in recurrent laryngeal nerve paralysis) • neurological diseases ▫ PD, MS, closed head injury, stroke, congenital conditions such as sulcus vocalis (vocal fold furrow) • should not be used in patients with voice problems due to vocal fold inflammation or mass lesions on the folds (i.e. nodules, polyps) • Pushing and pulling exercises should not be used with patients that have uncontrolled high blood pressure (Ramig & Verdolini, 1998) Purpose • Voice quality ▫ Facilitate improved vocal fold closure during voice production ▫ Helps to treat breathiness, low intensity, hoarseness, or overall vocal quality ▫ Conditions such as vocal fold bowing and vocal fold weakness or paralysis (Logemann, 1998) Purpose • Swallowing safety / airway protection • Increase muscle activity in the larynx • Basic to good laryngeal closure during swallowing • A sequence of these exercises should be completed before actual swallowing therapy ▫ if laryngeal incompetence can‟t be managed quickly by postural assists or teaching the patient to voluntarily close their airway (Logemann, 1998) Method • Two sets of exercises • The series of exercises should be completed five to ten time per day for five minutes • Each exercise should be repeated 5 times before moving on to the next exercise in the set • The whole series of exercises should be repeated three times (Logemann, 1998) Set 1 Exercise 1: Be seated. Hold your breath as tightly as possible while pushing down or pulling up on your chair with both hands for 5 sec. (Logemann, 1998) Set 1 Exercise 2: Be seated. Bear down against a chair with only one hand. Produce clear voice simultaneously. (Logemann, 1998) Set 1 Exercise 3: Repeat „ah‟ 5 times with a hard glottal attack on each vowel. (Logemann, 1998) Set 1 • Patients should practice this series every day for one week. • A follow-up swallow evaluation should be completed to assess improvements in airway protection from the larynx. • The SLP and patient can also monitor improvements in laryngeal function by listening to clarity and vocal quality. • If no improvements are noted, the exercises should be changed to those in Set 2. ▫ This prevents monotony and introduces exercises in a hierarchy (Logemann, 1998) Set 2 • The series of exercises should be completed five to ten time per day for five minutes • Each exercise should be repeated 5 times before moving on to the next exercise in the set • The whole series of exercises should be repeated three times (Logemann, 1998) Set 2 Exercise 1: Pull up on chair with both hands while prolonging phonation. (Logemann, 1998) Set 2 Exercise 2: Begin phonation of „ah‟ with a hard glottal attack and sustain phonation with a clear, smooth vocal quality for 5-10 seconds (Logemann, 1998) Set 2 Exercise 3: Pseudo-supraglottic swallow Take a breath, hold it, and cough as strongly as possible (Logemann, 1998) Recovery • Improvement should be seen within 2 weeks • Occasionally it will take 6-8 months with some patients to attain adequate airway protection or vocal quality ▫ these are often those who have had more serious conditions (i.e. extended supraglottic laryngectomy) (Logemann, 1998) Cautions • Stemple, Glaze & Klaben (2000) suggested that the effectiveness of these exercises depends on the degree of vocal fold gap ▫ prognosis for improvement is most favorable if a light touch closure is evident during the videostroboscopic evaluation • Patient should be monitored closely for signs of hyperfunction (Miller, 2004) (Stemple, Glaze & Klaben, 2000; Miller, 2004) Efficacy • There is very little research about the use and efficacy of laryngeal adduction exercises. • Since there are extremely few efficacy studies concerning vocal fold adduction exercises, few SLPs currently use the pushing and pulling type of exercises. ▫ Yamaguchi et al. (1990) ▫ Silverman Voice Treatment (LSVT) Yamaguchi et al. (1990) • Cases of glottal incompetence • Treated by the pushing exercises technique. • Three patients that had paralysis of the vocal folds or sulcus vocalis • All three individuals improved following voice treatment. ▫ Two improved 20 dB (statistically significant increase in intensity), and one improved 7 dB (clinically significant increase in intensity). LSVT • The Lee Silverman Voice Treatment (LSVT) program utilizes intensive high phonatory effort exercises in order to increase vocal fold adduction. • It has been documented to have short and long term effectiveness for those with idiopathic Parkinson‟s Disease. (Ramig, 1998) Vocal Function Exercises “Knoll” Who? • Beneficial to treat ▫ Hyperfunction Too much laryngeal activity ▫ Hypofunction Too little laryngeal activity • Prevention ▫ Hyperfunction ▫ Vocal symptoms • Research has demonstrated improvements for ▫ Vocal nodules ▫ Singers ▫ Aging voice Philosophy • The laryngeal mechanism, like other muscle systems, may become imbalanced and/or strained. • VFE treat in a holistic manner. • “Physical therapy” for the voice (Stemple, Glaze, & Gerdeman-Klaben, 2000) Purpose • Increase the bulk, strength, and coordinated interaction of muscles • Improved glottal efficiency • Improved vocal quality ▫ Easy onset ▫ Frontal focus ▫ Respiratory support ▫ Balance respiration, phonation, & resonance (Stemple, 2000; “Vocal function exercises”, n.d.) Method • Set of 4 exercises • Completed 2x each, 2x daily ▫ 1x in the morning, 1x in the afternoon • Complete as softly as possible to ▫ Purpose: increase muscular and respiratory effort to maintain phonation (Andrews, 2006) Step 1: Warm-Up • Sustain the vowel /i/ for as long as possible ▫ on a musical note F above middle C for women and children below middle C for men. May be modified based on patient‟s vocal range. • Goal ▫ Dependent on patient‟s airflow volume. ▫ Targeted volume is 80-100 mL/s of airflow. Flow volume, mL H2O/100 mL H2O = _______ seconds (Stemple, Glaze, and Klaben, 2000; Andrews, 2006) Step 2: Stretching • Say “Knoll” and glide from lowest note to highest note in vocal range. • Goal ▫ Complete without voice breaks. ▫ Use of the word “knoll” encourages a forward vocal focus and an open pharynx. ▫ Lips should be rounded and the patient should feel vibration on the lips. ▫ During this exercise, vocal folds are stretched 2006) (Stemple, Glaze, and Klaben, 2000; Andrews, Step 3: Contraction • Say “Knoll” and glide from highest note to lowest note in vocal range. • Goal: ▫ Complete without voice breaks. ▫ Encourages a forward focus and an open pharynx. ▫ Complements the previous stretching exercise by contracting the laryngeal muscles. (Stemple, Glaze, and Klaben, 2000; Andrews, 2006) Step 4: Adductory Power Exercise • Voice “Oll” (“knoll” without “kn”) as long as possible on musical notes C, D, E, F, and G ▫ above middle C for women and children ▫ below middle C for men modify based on patient‟s vocal range). • Goal ▫ dependent on patient‟s airflow volume. ▫ The goal is the same as the first exercise with a targeted volume is 80-100 mL/s of airflow. (Stemple, Glaze, and Klaben, 2000; Andrews, 2006) Recovery • Patients track progress on a graph ▫ Sustained times ▫ Daily variation is expected • Improvement typically seen within 6-8 weeks (Stemple, Glaze, and Klaben, 2000) Maintenance Once goals have been met and vocal quality has improved, the following weekly program is recommended: Full program 2 times each, 2 times per day Full program 2 times each, 1 time per day (morning) Full program 1 time each, 1 time per day (morning) Exercise #4, 2 times each, 1 time per day (morning) Exercise #4, 1 time each, 1 time per day (morning) Exercise #4, 1 time each, 3 times per week (morning) Exercise #4, 1 time each, 1 time per week (morning) (Stemple, Glaze & Klaben, 2000) Efficacy Voice Therapy: Clinical Studies (Stemple, 2000) Provides a variety of cases in which he has used VFE • Hyperfunction • Hypofunction ▫ 9 year old ▫ 71 year old ▫ 21 year old ▫ 36 year old ▫ Improved vocal quality ▫ Improved efficiency of Easy onset, respiratory breath support for support, frontal focus phonation Balance among respiration, phonation, resonance • Treatment of vocal nodules ▫ 26 year old • Prevention of hyperfunction ▫ Improved vocal quality ▫ 53 year old Overall improvement in ▫ Avoid hyperfunction as a vocal folds new, higher pitch is learned Frontal focus Increased MPT Prevention of Vocal Symptoms • Pasa, Oates, & Dacakis (2007) ▫ 37 primary school teachers ▫ Ages: 21 to 55 ▫ Results Decrease in vocal symptoms Improved vocal quality Increased maximum phonation times Singers • Wrycza-Sabol, Lee, and Stemple (1995) ▫ 20 healthy graduate-level voice majors ▫ Ages 21 to 55 ▫ Results: Improved glottal efficiency Increased airflow rates Imporved phonation volumes Increased MPTs Aging Voice • Gorman, Weinrich, Lee, and Stemple (2008) ▫ 19 male participants ▫ Ages 60 to 78 ▫ Results: Continuous improvements in MPT Improved glottal closure References • Andrews, M.L. (2006). Manual of voice treatment: Pediatrics through geriatrics. Thomson: Canada. • Gorman, S., Weinrich, B., Lee, L., & Stemple, J.C. (2008). Aerodynamic changes as a result of vocal function exercises in elderly men. The Laryngoscope, 118, 1900-1903. • Logemann, J.A. (1998). Management of the patient with oropharyngeal swallowing disorders. Evaluation and Treatment of Swallowing Disorders. Pro-Ed: Austin, TX. • Miller, S. (2004). Voice therapy for vocal fold paralysis. Otolaryngologic Clinics of North American, 37, 105-119. • Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logopedics Phoniatrics Vocology 32, 128-140. • Ramig, L.O. & Verdolini, K. (1998). Treatment efficacy: voice disorders. Journal of Speech, Language, and Hearing Research, 41, 101-116. • Stemple, J.C. (2000). Voice therapy: Clinical studies. Delmar: Canada. • Stemple, J.C., Glaze, L.E., & Gerdeman-Klaben, B. (2000). Clinical voice pathology: Theory and management. Singular: Canada. • Vocal function exercises. In Vocology. Retrieved July 13, 2009, from http://ncvs.org/museum-archive/vocologyguide.pdf • Wrycza-Sabol, J., Lee, L., & Stemple, J.C. (1995). The value of vocal function exercises in the practice of regimen of singers. Journal of Voice, 9(1), 27-36. • Yamaguchi, H., Watanabe, Y., Hajime, H., Kobayashi, N. & Bless, D.M. (1990). Pushing exercise program to correct glottal incompetence. Annual Bulletin of the Research Institute of Logopedics, 24, 223-234.